HomeMy WebLinkAboutBLD2022-01405 - BLD CD Environmental Health Review - 11/1/2022 y,i—• 3 't4+a�r MASON COUNTY COMMUNITY SERVICES Permit No Id W�t vtw I
` PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL (
(1. 615 W.Alder Street,Shelton.WA 98584 I \f l
--�� 'I Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
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�'',r Belfair.(360)275-4467.Phone Elmar(360)482-5269 -�,•,J
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BUILDING PERMIT APPLICATION v
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: 61 15
NAME:C&C Development �!`1Or c�ft-'
NAME:Donald Prouty t
MAILING ADDRESS:990 E Strong Rd MAILING ADDRESS:145 Pattee Rd
CITY:Shelton STATE:WA ZIP:98584 CITY:Chehalis STATE:WA ZIP:98532 ��
PHONE#1:360-831-7244 PHONE:360-508-1220 CELL: C
PHONE#2: EMAIL: ode elopment@hotrnail.com \q`
EMAIL:dwp9852@yahoo.com L&I REG#CCDEVCD811 BT Exp. 02. /22. �3 \•••,
PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER 0
NAME Donald Prouty EMAIL dwp9852@yahoo.com
MAILING ADDRESS 990 E Strong Rd CITY Shelton STATE WA eA9988584
PHONE CELL 360-831-7244 I,/f 11
PARCEL INFORMATION: •o �/�/
PARCEL NUMBER(12 Digit Number) 22128-77.0080 ZONING ���4�`f ' Y �1�/
LEGAL DESCRIPTION(Abbreviated) TR 8 of Survey 8/76(GL 5)S 51/33 FIRE DISTRICT
ii
691 E Strong ADDRESS Rd CITY Shelton
DIRECTIONS TO SITE ADDRESS From Shelton north on hwy 3 to Pickering Rd.east on Pickering to Strong Rd,north on Strong
site is on the west side of Strong Rd
IS THE PROJECT WITHIN 300 FI OF SLOPE(S)GREATER THAN 14%: YES❑ NO❑Q SNOW LOAD:_psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply):
SALTWATER 0 LAKE❑ RIVER/CREEK 0 POND❑ WETLAND❑ SEASONAL RUNOFF 0 STREAM 0
TYPE OF WORK: NEW 0 ADDITION 0 ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence,Garage.Commercial Bldg.Etc.)Garage/Shop
IS USE: PRIMARY 0 SEASONAL 0 NUMBER OF BEDROOMS 0 NUMBER OF BATHROOMS 1
HEATED STRUCTURE? YES(Whole Bldg)B YES(Parris]of Bldg)❑ NO 0
DESCRIBE WORK Erect on slab a steel structure.
SQUARE FOOTAGE: (proposed)
1ST FLOOR 2400 sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached 0 CARPORT sq.ft. Attached 0 Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
kWIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC 0 SEWER❑ / NEW' EXISTING 0
PLUMBING IN STRUCTURE? YES B NO❑ If yes,attach completed Water Adequacy Form
PERIMETER/FOUNDATION INS PROPOSED? YES 0 NOD EXISTING SQ.17.
EXISTING BEDROOMS L PROPOSED BEDROOMS 0 TOTAL BEDROOMS
OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.Acknowle gement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal
representative,represents that the information provided is accurate and grants employees of Mason County access to the above described property
and structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 180 days.
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERM APP TION OF 180 DAYS OF MOUE WILL CAUSE a THE APPLICATION TO BE EXPIRED.(MASON
(c. ------ C
Signature Must be signed by the OWNER)
Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH kl I t riz,5 C. I S V'1I I I %!
• . ` • \
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` ' APPRQX.
E I°=300' \ STRONG ROAD
• ' '• �� \ • \ \�` (60'EASEMENT)
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EH Setbacks hi ,� , PROPOSED 6 BEDROOM ,
A.) Drainfield:Reserve requires 10'setback from footing/foundation P RI MARE A RESERVE
B.)Septic tank(s)requires 5'setback from all footing/foundations . / i
C.)No foundation/Perimeter Drains within Mt.downgradient of, / / t
p t
Drainfield/Reserve area /
D.)No Cut Bank(s)(greater than 5ft and over 45 degrees)wit / //
50ft.down gradient of Drainfield/Reserve area ` ,/ / 0 1/44
PROPOSED SHOP 1 / /
/ /
W/ PLUMBING O ItV I;' fr/RO ?� F"
(TO BE CONSTRUCTED � }
PRIOR TO HOME) / / ` i.,
PROPOSED SEPTIC TANK LOCATIA \I.
° \\ (MAINTAIN 50'+ FROM PRIVATE WELLS) f
I EH APPROVED ti
Rhonda Thompson 01,132023
/ INSTALL CLEANOUTS AT BBB
/�'_ /�•s / 1.� EACH CONNECTION
y0/ POINTAND EVERY100FT 1
,./' \ / - // / \ / TO SEPTIC TANK.
/ .° \ MAINTAIN 10FT SETBACK
FROM SEPTIC TAN K AN D
/i - • �.`\\// \\t FUTURE ++�.` POTABLE
/ \,/\ HOME / ++ LINES TO
/ p \ WATERLINES •
LOB►:TION / +s 4 o'�^d "f`:
•
/ t -$ l •i
;`1•�" 'ODD. ipAY56E " "`
° POSSIBLE WELL SITE i _. .
N i:Xc•iRES 13\cr zz—b 140s
(MAINTAIN 50F1 TO TANK
\ AND SEPTIC LINES) AN ASBUILT/INSTALL SIGNOFF FEE WILL
\ / i
BE CHARGED AT TIME OF INSTALLATION i
' CUSTOMER DONAL D PROLTTY T HOLE 1: TEST HOLE 2 TEST HOLE 3:
PIONEER DIGGING INC. PARCEL 22128 77-0ooso `cMs GLS
i%oGn>s 042 CIS
48+ � , w�
SEPTIC DESIGNS ADDRESS: ,00(ESTR.•NC R• REFERENCES
PLATS O RR THE, MEASURE. NAND COUNTY GIS DESIGN I" NTENDED�ON Sc 1'
3083E MASON BENSON RD. GRMEVIEW,WA 98546 DESIGNER: ROBERT H.PAYSSE � �FIELD PROPOSED ��,�,� ,ME .E SUBJECT .o
OFFICE 360 4261803 FAX•360 427 2353 SHEET: SITE PLAN SCALE 1"=5�' SEPTIC COMPONENTS.R��DESIGNER NOT RESPONSIBLE FOR SETCMC(S U TeL -l4
WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE50830
ECOLOGY unique Ecology Well ID Tag No. BNV824
Type of Work State of Washington
Site Well Name(if more than one well):
O Dm sn Water Right Permit/Certificate No.
❑ Deccotrommission � Originalinstallationgtninstallation NOI No.
Proposed Use, 17 Domestic 0 Industrial 0 Municipal Property Owner Name Don Pro
0 Dewatcring 0 Irrigation ❑Test Well 0 Other_________ Well Street Address 691 E Strong Rd
Method: City Shelton County Mason
0 Deepening 0 O
Construction Type: 0 Driven ❑Jetted ❑Cable Tool
New well ❑ tteration 0 Dug fill Air- ❑Mud-Rotary Tax Parcel No. 22128-77-00080
ther�_
Dimensions: Diameter of boring 6 in.,to 218 ft_ Was a variance approved for this well? 0 Yes • No
Depth of completed well________218 ft If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread WWM or CI EWM
0 213 .025 in. C I 0 E I ❑ Location(see instructions on page 2):
0 I 0 6 in.❑ I ❑ in. in. ❑ I
0 ❑ I ❑ SE 1/4-1/4 of the SE '/.;Section 28 Township 21N Range 2W
__
❑ I 0 in. — — in. ❑ I 0 0 I 0
Latitude(Example:47.12345) 47.275973 N
❑ I ❑ in ❑ I ❑ I hngitude(Example:-12O.l,2345) -122.933073 W -
Perforations: ❑Yes ®r No
T perforator razor used Driller's Log/Construction or Decommission Procedure
No.of perforations_ Size of perforations_in_by—'a Formation Describe by color,character,size of material and structure,and the kind and
Perforated from it to
it below groundsurfacenature of the material in each layer penetrated,with at least one entry for each change of
_ information Use additional sheets if ne �ssary'.
K-Packer r� Depth 212 ft
Screens: ®Yes 0 No Material From To
Manufacturer's Name Allo Machine Works 0
Type Wire Wrapped Model No. Brown fine to medium sandy gravel,siltbound
213 ft.to 218 ff 21
Diameter 5__ Slot size.018 to from fi to Xi tight,dry 77
Diameter_ slot sill_ from Brown gravelly fine sand,silty,tight,dry 21
No Size of _ gravel,loose,moist 77 114
Sand/Filter pack:❑Yes fk material Brown medium sandy 114
Materials placed from_ft_to___ft. Black fine sandy sharp gravel,clay binder 18
Surface Seal: E Yes 0 No To what depth? 19 ft 1
gray,dry 118 118
Material used in seal Bentonite Chsi Gray day,stiff,dry 138
26
Black gravelly fine silty sand,soupy 126
Did any strata contain unusable water? 0 Yes ENo 138 138
Type ofwaz«? Depth of strata Gray clay,stiff,dry
138 160
Method of sealing strata off Blue clay,stiff,dry 140
Pomp: Manufacturer's Name____ Type:_— Black fine sandy gravel,gray silt binding, 164
H.P._ Pump intake depth:_ft Designed Sow rate:_gpm tl•ht,d 179
164
Water Levels: Land-surface elevation above mean sea level 215 ft. Gray clay,stiff,dry 4 179
Stick-up of top of well casing 1 ft above ground surface Gray clay with black gravel,tight,dry 179184 189
Static water level 157 R below top of well casing Date 12129/22 Multicolored coarse sandy gravel,loose,dry
lbs.per square inchgravel 189 189
Artesian water is_ Date Gray silt binding black sharp
93
(cap,valve,etc.)
Artesian water is controlled by�— Black medium to coarse sandy gravel,heaving 193 218
3
Wen Tests:
Black coarse sandy gravel,water 213
Was a pumping test performed? El No 0 Yes by whom?
Yield_gpm with_ft dtawdown after__hrs.
Yield gin with—ft drawdown after hrs.
Yield gpm with_ft drawdown after__hrs.
Recovery data(time a zero when pump is turned off-water level measured from well
top to water level) Water Level Time Water Level
Time Water Level Time
Date of pumping test
Bailer test gpm with—Er_drawdown after-_hrs.
Air test 20 gpm with stem set at 200 ft.for I hrs. Date 12/29/22
l
Artesian flow_gpm Start Date 12/'19(22 Completed Date 12/29l22
Temperature of water 51 °F Was a chemical analysis made? ❑Yes i7 No
WELL CONSTRUCTION CERTIFICATION:ed and the Iconstructed
information report and/oro accept
tre responsibility
sibilli y for
knowledgeoction of ion belief.this well,and its compliance with all Washington well
are
construction standards.Materials
hythian _ Drilling Company Arcadia Drilling Inc.
l Driller❑Trainee 0 PE-P• Address PO Box 1790
L lure City,State,Zi Shelton,WA 98584
License No. 2053 Contractor's
IF TRAINEE:S onsor's Licens o. Date 12l29122 _
Registration No.ARCADDI098K1
S nsor's Si afore
ECY 050-1-20(Rev 09/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
1786 SE Mile Hill Drive
Port Orchard,WA 98366
__� S TRA PEC Laboratories-Kitsap w-ww.spectra-lab.corn
_10101.?..rswca..rtsr+ (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected lime Sample County
Collected
1 I 5 I 23 ❑A+
3 15 Mason
•Mach Day Y. ---•—(ji pu
Type of Water System(check only one box) —
❑Group A ❑Group B 0Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IDd
System Name: Don Prouty
Contact Person:Arleta Eisele/Arcadia Drilling
Day Phone:380 d26-396 Cell Phone:
Email: arleta@arcadiadriiling.com Eve.Phone:
Send results b:(Print full name,address and sip code or e-mai)
arletaiparcadiadriliing.com
Arcadia Drilling,Inc
SAMPLE INFORMATION
Sample collected by(name):Seth
Specific location where sample collected: Special instructions or comments:
#BNV824
691 E Strong Rd,Shelton
Type of Sample(check only one box)
1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes❑ No❑ 0 Distnbunon System
Chlorine Residual:Total_Free_ Unsatisfactory routine lab number:
3.Source Ground Water Rule Sample ___ ————
S l ! Unsatisfactory routine collect date:
❑Triggered Chlorinated:Yes ElNo❑
Chlorine Residual:Total___Free_—
El Assessment
4. Frumera6on Souce Water Some — — t S i I 1
❑E.coli DFecal-Surf:m.0N%Bprirys;nMrad Y""O goo
5.O Sample Ccke;,ted for Inrunnavon Only.
LAB USE ONLY DRINKING WATER RESULTS t.r LAB USE ONLY
0 Unsatisfactory Total Colilorm Present and 3 tlstactory
❑E.coli Osent 0 Ecoli absent
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑Bacterial Density Results:Total Colitorm__ _____110Om1. E.coli_ _/100mI.
Fecal Coliform _J100m1. HPC.________ _J1 ml.
Lab ID Num r Date and Time f2eceivect R T
1 ci 6 2023 .�� �1
Method Code: Date and Time Incubated:
SM 9223 B _ :1. , 1 CT 2023
1ANb2o�z Jn I
Date Analyzed: Dale Reperte lAY�y zezz
COM labSample:4 � tab Use Only:
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